Published recently in the Journal of Psychiatric Research, this is a rigorously conducted study that suggests that referrals and presentations to most secondary mental health services reduced and mortality for severe mental illness increased during the pandemic.
RR:C19 Evidence Scale rating by reviewer:
Strong. The main study claims are very well-justified by the data and analytic methods used. There is little room for doubt that the study produced has very similar results and conclusions as compared with the hypothetical ideal study. The study’s main claims should be considered conclusive and actionable without reservation.
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Review:
The study presented in the abovementioned manuscript examined changes in presentations and referrals to mental health service providers in Cambridgeshire and Peterborough, UK during the initial COVID-19 “lockdown” measure (March 23, 2020 to May 10, 2020). Utilizing the “lockdown” for an interrupted time series analysis of anonymized information from National Health Service data bases appeared appropriate. This methodological point is important to state, given the nature of the findings presented by the authors. Principally, this study reports a decrease in referrals and presentations to most secondary mental health care services—with evidence of decreases to both supply and demand—and an increase in mortality among those with severe mental illness.
Overall, the claims made by the investigators were strong and supported by the data and methods used. To a lesser degree, the claims made in the study should be considered reliable by decision makers, yet limited by their current actionable value. This assessment is based on the strength of the methods utilized to derive the principal findings, but also the limitations characterized by the numerous decision-relevant questions that have yet to be addressed. For instance, in addition to mortality rates increasing among those with severe mental illness, has there also been increased graduation from moderate to severe levels of mental health status during the period of study? While the authors note the important potential impacts of the “lockdown” on psychological and psychiatric consequences, such as bereavement due to COVID-19, reduced social opportunities, loneliness, and anxiety over illness and death, other key determinants were not highlighted. Chief among these include employment disruption, negative financial impacts, and substance misuse, which have been noted in the literature during the pandemic (Brooks et al. 2020; Columb et al. 2020; Price 2020). While the authors do state that more needs to be discovered as to why service utilization was decreasing, this point requires greater articulation to help guide the field forward. For example, the impact of stigma and normalization of stress in crisis potentially affecting help-seeking behaviour remains an untapped area of study during the pandemic (Salaheddin and Mason 2016).
Indeed, while it does appear that this paper contributes to a broader understanding of mental health service utilization during COVID-19, the study, generally, was not clearly placed within the context of current literature. The introduction references several studies relating to the neurotropic effects of COVID-19 in humans, which bear minimal relevance to the topic of study. In reference to studies accounting for the psychological and psychiatric effects of the pandemic, only two studies were cited as background. This is not for lack of evidence on the topic of public mental health during COVID-19 (Ahorsu et al. 2020; Cao et al. 2020; Gritsenko et al. 2020; Huang and Zhao 2020; Price 2020). In the discussion section on mortality, the authors note the important increased risk of those over age 70 with severe mental illness and cite relevant comorbidities, such as diabetes and cardiovascular disease which have been attributed with increased risk of adverse COVID-19 health outcomes. Missing from this section, however, was reference to work on the negative mental health effects of isolation, anxiety, depression and fear for this age cohort during COVID-19 (Morrow-Howell et al. 2020).
This paper presents important findings, based on sound methods, and makes reasonable conclusions. With some minor revisions to place it more appropriately within the rapidly emerging extant literature, to highlight relevant limitations, and to provide greater guidance on areas of further study, noted above and beyond, it will make it a valuable addition to this field of research.
References
Ahorsu DK, Imani V, Lin C, et al (2020) Associations between fear of COVID-19, mental health, and preventive behaviours across pregnant women and husbands: An actor-partner interdependence modelling. Int J Ment Heal Addict Addict June: https://doi.org/https://doi.org/10.1007/s11469-020-00340-x
Brooks SK, Webster RK, Smith LE, et al (2020) The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 395:912–920. https://doi.org/https://doi.org/10.1016/S0140-6736(20)30460-8
Cao W, Fang Z, Hou G, et al (2020) The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Res 287:112934. https://doi.org/10.1016/j.psychres.2020.112934
Columb D, Hussain R, O’Gara C (2020) Addiction psychiatry and COVID-19: Impact on patients and service provision. Ir J Psychol Med 1–15. https://doi.org/10.1017/ipm.2020.47
Gritsenko V, Skugarevsky O, Konstantinov V, et al (2020) COVID 19 fear, stress, anxiety, and substance use among Russian and Belarusian university students. Int J Ment Health Addict 1–7. https://doi.org/10.1007/s11469-020-00330-z
Huang Y, Zhao N (2020) Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: A web-based cross-sectional survey. Psychiatry Res 288:112954. https://doi.org/10.1016/j.psychres.2020.112954
Morrow-Howell N, Galucia N, Swinford E (2020) Recovering from the COVID-19 Pandemic: A Focus on Older Adults. J Aging Soc Policy 32:526–535. https://doi.org/10.1080/08959420.2020.1759758
Price A (2020) Online Gambling in the Midst of COVID-19: A Nexus of Mental Health Concerns, Substance Use and Financial Stress. Int J Ment Health Addict. https://doi.org/10.1007/s11469-020-00366-1
Salaheddin K, Mason B (2016) Identifying barriers to mental health help-seeking among young adults in the UK:a cross-sectional survey. Br J Gen Pract 66:e686–e692. https://doi.org/10.3399/bjgp16X687313
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